Human intestinal enteroids and predictive models validate the operational limits of sanitizers used for viral disinfection of vegetable process wash water.

Vegetables are globally associated with a considerable number of foodborne outbreaks caused by viral infections, specifically human norovirus. In fresh produce industry, washing represents a critical step for food safety as process wash water (PWW) needs to be maintained at appropriate microbial quality to prevent water-mediated cross-contamination. This study aimed to explore the disinfection efficacy of chlorine (free chlorine, FC), chlorine dioxide (ClO2) and peracetic acid (PAA) in PWW against infectious human norovirus and Tulane virus (TV). First, we tested the extent of TV inactivation in baby leaf, bell pepper, and vegetables mix PWW and monitored the viral decay by cell culture. Then, inactivation kinetics were defined for infectious human norovirus exposed to FC, ClO2 and PAA in baby leaves PWW using the human intestinal enteroids (HIE) system. Finally, kinetic inactivation models were fitted to TV reduction and decay of sanitizers to aid the implementation of disinfection strategies. Results showed that >8 log10 human norovirus and 3.9 log10 TV were inactivated by 20 ppm FC within 1 min; and by 3 ppm ClO2 in 1 min (TV) or 5 min (norovirus). PAA treatment at 80 ppm reduced ca. 2 log10 TV but not completely inactivated the virus even after 20 min exposure, while 5 min treatment prevented norovirus replication in HIE. TV inactivation in PWWs was described using an exponential decay model. Taking these data together, we demonstrated the value of applying the HIE model to validate current operational limits for the most commonly used sanitizers. The inactivation kinetics for human norovirus and TV, along with the predictive model described in this study expand the current knowledge to implement post-harvest produce safety procedures in industry settings.

Effect of the Use of Gnrh Analogs in Low-Grade Cerebral Glioma.

Low-grade gliomas are the most common brain tumors in children. This tumor type presents a wide range of clinical, histological, and biological behaviors. In recent years, an association between estrogens and progesterone and the development of tumors has been suggested. A case of a 2-year-old girl is described with a low-grade brain tumor treated with chemotherapy and disease stabilization. The treatment with Decapeptyl® was initiated due to precocious puberty, and the tumor showed a decrease in its solid component-more than 50% of the initial size-three years after starting treatment. Several studies have described the influence of estrogen and progesterone on the development of gliomas, decreasing or increasing their expression in those tumors with greater aggressiveness, respectively. Despite the fact that the tumor-hormonal expression relationship in other tumor types has been evaluated, its role in the treatment of brain tumors remains unknown.

Assessment and Prediction of Fish Freshness Using Mathematical Modelling: A Review.

Fish freshness can be considered as the combination of different nutritional and organoleptic attributes that rapidly deteriorate after fish capture, i.e., during processing (cutting, gutting, packaging), storage, transport, distribution, and retail. The rate at which this degradation occurs is affected by several stress variables such as temperature, water activity, or pH, among others. The food industry is aware that fish freshness is a key feature influencing consumers' willingness to pay for the product. Therefore, tools that allow rapid and reliable assessment and prediction of the attributes related to freshness are gaining relevance. The main objective of this work is to provide a comprehensive review of the mathematical models used to describe and predict the changes in the key quality indicators in fresh fish and shellfish during storage. The work also briefly describes such indicators, discusses the most relevant stress factors affecting the quality of fresh fish, and presents a bibliometric analysis of the results obtained from a systematic literature search on the subject.

[Experience with Denosumab in central giant-cell granuloma]. / Experiencia con Denosumab en granuloma central de células gigantes.

INTRODUCTION: Central Giant Cell Granuloma is an infrequent bone lesion located mainly in the maxillary bone. The main treatment is surgery with wide margins, so it sometimes causes great morbidity and esthetic al terations. Denosumab, a RANK-ligand inhibitor monoclonal antibody, has been presented as a valid therapeutic alternative in the treatment of these lesions. OBJECTIVE: to describe the clinical and radio logical response after treatment with Denosumab in a patient with unresected giant cell granuloma. CLINICAL CASE: 12-year-old boy who consulted due to a 24-hour maxillary swelling, without other associated symptoms. Examination revealed a tumor in the upper left maxilla with bulging of the ip- silateral gingiva. A CT scan was performed which showed a large expansive intraosseous lesion in the maxillary alveolar ridge. The biopsy of the lesion was compatible with Central Giant Cell Granuloma. Due to the size and location of the lesion, initial treatment with Denosumab, a human monoclonal antibody with action on RANK-ligand, was indicated. After 10 months of treatment, the patient showed a favorable clinical and radiological response, with a size decrease of the lesion and metabolic activity. As an adverse effect, the boy presented mild hypocalcemia, resolved after supplementation with calcium. CONCLUSION: the use of Denosumab as the first line of treatment in Giant Cell Granu loma may be an adequate therapeutic option in adolescents with lesions that are difficult to resect.

A Dynamic Approach for Early Risk Prediction of Gram-Negative Bloodstream Infection and Systemic Inflammatory Response Syndrome in Febrile Pediatric Hemato-Oncology Patients.

Background: The aim of this study was to evaluate the usefulness of C-Reactive Protein (CRP), Procalcitonin (PCT), and Interleukine 6 (IL6) biomarkers in predicting the existence of high-risk episodes (HRE) during the first 24 h of fever in pediatric cancer patients. HRE were defined as the presence of Gram-negative bloodstream infections or Systemic Inflammatory Response Syndrome. Methods: The study included 103 consecutive fever episodes in 44 hemato-oncological pediatric patients, from whom samples for biomarkers were taken upon initial evaluation (CRP-1, PCT-1 and IL6-1) and then between 12 and 24 h afterward (CRP-2, PCT-2 and IL6-2). Results: An IL6-1 value higher than 164 pg/mL showed an area under the curve (AUC) of 0.890 (0.791−0.989) and OR of 48.68 (7.92−951.42, p < 0.001) to detect HRE in multivariate analysis. A PCT-1 higher than 0.32 ng/mL showed an AUC of 0.805 (0.700−0.910) and OR of 4.55 (0.90−27.84, p = 0.076). A PCT-2 higher than 0.94 ng/mL showed an AUC of 0.836 (0.725−0.947) and OR of 13.01 (1.82−149.13, p = 0.018), and an increase in CRP between the first and second sample (CRP-2vs1) higher than 291% also showed an AUC of 0.785 (0.655−0.915) and OR of 31.09 (4.87−355.33, p = 0.001). Conclusions: IL6-1, PCT-2, and CRP-2vs1 showed a strong and independent correlation with HREs in pediatric cancer patients. CRP variations over the first 24 h provide an improvement in predictive models that are especially useful if IL-6 and PCT are not available.

Biomarkers and Fever in Children with Cancer: Kinetics and Levels According to Final Diagnosis.

We investigated the kinetics of CRP, PCT, IL-6 and MR-proADM in a cohort of consecutive febrile patients with cancer in order to test the hypothesis that higher plasma concentrations and the absence of a rapid decrease in peak values would be associated with disease severity. (1) Method: A prospective descriptive and analytical study of patients with cancer and fever (≤18 years of age) at a University Hospital was carried out between January 2018 and December 2019. Information collected: sex, age, diagnosis, date and symptoms at diagnosis and medical history. The episodes were classified into three groups: bacterial infection, non-bacterial infection and systemic inflammatory response syndrome (SIRS). (2) Results: One hundred and thirty-four episodes were included. Bacterial infection criteria were met in 38 episodes. Biomarkers were measured at four different points: baseline, at 12-24 h, at 25-48 h and at 49-72 h. All the biomarkers evaluated decreased after the peak level was reached. IL-6 and MR-proADM showed a trend towards higher levels in the SIRS group although this rise was statistically significant only for IL-6 (p < 0.005). Bacterial infections more frequently presented values of PCT above the cut-off point (>0.5 ng/mL) at 12-24 h. (3) Conclusion: In our experience, IL-6 kinetics is faster than PCT kinetics and both are faster than CRP in patients with fever and cancer who present a good outcome. Patients with a good evolution show a rapid increase and decrease of PCT and particularly of IL-6 levels.

Mortality in Patients with Diabetic Foot Ulcers: Causes, Risk Factors, and Their Association with Evolution and Severity of Ulcer.

Background: This study reviews the mortality of patients with diabetic foot ulcers (DFU) from the first consultation with a Multidisciplinary Diabetic Foot Team (MDFT) and analyzes the main cause of death, as well as the relevant clinical factors associated with survival. Methods: Data of 338 consecutive patients referred to the MDFT center for a new DFU during the 2008-2014 period were analyzed. Follow-up: until death or until 30 April 2020, for up to 12.2 years. Results: Clinical characteristics: median age was 71 years, 92.9% had type 2 diabetes, and about 50% had micro-macrovascular complications. Ulcer characteristics: Wagner grade 1-2 (82.3%), ischemic (49.2%), and infected ulcers (56.2%). During follow-up, 201 patients died (59.5%), 110 (54.7%) due to cardiovascular disease. Kaplan-Meier curves estimated a reduction in survival of 60% with a 95% confidence interval (95% CI), (54.7-65.3) at 5 years. Cox regression analysis adjusted to a multivariate model showed the following associations with mortality, with hazard ratios (HRs) (95% CI): age, 1.07 (1.05-1.08); HbA1c value < 7% (53 mmol/mol), 1.43 (1.02-2.0); active smoking, 1.59 (1.02-2.47); ischemic heart or cerebrovascular disease, 1.55 (1.15-2.11); chronic kidney disease, 1.86 (1.37-2.53); and ulcer severity (SINBAD system) 1.12 (1.02-1.26). Conclusion: Patients with a history of DFU have high mortality. Two less known predictors of mortality were identified: HbA1c value < 7% (53 mmol/mol) and ulcer severity.

[Ototoxicity in cancer survivors: experience and proposal of a surveillance protocol]. / Ototoxicidad en pacientes oncológicos: experiencia y propuesta de un protocolo de vigilancia.

INTRODUCTION: Ototoxicity occurs in different percentages in patients after treatment with platinum-based chemotherapy or cranial radiation therapy. The aim of this study was to present experience in ototoxicity monitoring. MATERIAL AND METHODS: A review was made of the registry of paediatric cancer patients referred to the Children's Hearing Loss Unit from 1999 to 2019. RESULTS: Of the 46 patients referred to this unit, 41 had received platinum as part of their treatment, 17 patients underwent neurosurgery, and 18 patients received cranial radiation therapy. An anamnesis and otoscopy were performed on all of them, and the monitoring was carried out with tone-verbal audiometry and/or distortion products. Hearing loss was observed in eight patients (21.05% of patients referred for audiological follow-up) as a consequence of the treatment. It was impossible to determine the audiological situation in eight patients at the end of treatment. Hearing aid adaption was necessary in two patients. In coordination with Paediatric Oncology, a change from cisplatin to carboplatin due to bilateral grade two ototoxicity was considered appropriate during treatment in one patient. CONCLUSION: Adequate coordination with Paediatric Oncology is essential to carry out active surveillance for ototoxicity and to modify, if possible, the dosage or type of chemotherapy in case hearing is affected. In our experience, and following current recommendations, a pre-treatment assessment is usually performed, as well as monitoring during treatment, at the end of treatment, and annually thereafter due to the risk of a later development of hearing loss.

Spanish translation, adaptation and validation of the Hypoglycemia Fear Survey in adults with type 1 diabetes in the Community of Madrid. / Traducción al español, adaptación y validación del Cuestionario de miedo a la hipoglucemia en adultos con diabetes tipo 1 de la Comunidad de Madrid.

BACKGROUND AND OBJECTIVE: The negative impact of hypoglycemia on patients with type 1 diabetes mellitus (T1DM) may lead to development of fear of hypoglycemia. In this study, the original Hypoglycemia Fear Survey (HFS) questionnaire was translated into Spanish, adapted and validated, and variables associated to fear of hypoglycemia in T1DM were analyzed. MATERIAL AND METHODS: The HFS was translated and adapted to Spanish using the forward-backward translation method. The resulting questionnaire, EsHFS, was administrated to a population with T1DM. The following parameters of the questionnaire were analyzed: feasibility, reliability (Cronbach's alpha), content validity (correlating EsHFS and EsDQOL [Diabetes Quality of Life] questionnaire), and stability (by means of test-retest correlation). RESULTS: The EsHFS questionnaire consists of 24 items and three subscales including: subscale 1 on worry; subscale 2 on hypoglycemia-avoidant behavior, and subscale 3 on hyperglycemia-influenced behavior. STUDY POPULATION: 163 subjects, with a mean aged (SD) of 36 (10.5) years, 24% on continuous subcutaneous insulin infusion. Of these, 99.8% completed the EsHFS questionnaire in less than 10minutes. Cronbach's alpha for global EsHFS was 0.92. EsHFS and its subscales correlated with EsDQOL. Test-retest correlation (Pearson) was r=0.92. Age, female sex, lower educational level, living alone, frequency of daily self-monitoring and non-severe hypoglycemia, and history of severe and/or asymptomatic hypoglycemia were independently associated to the result of EsHFS. CONCLUSIONS: The Spanish version of the HFS, EsHFS, has good psychometric properties and may be a useful tool to assess fear of hypoglycemia in Spanish-speaking patients with T1DM.

Analysis of recurrent ulcerations at a multidisciplinary diabetic Foot unit after implementation of a comprehensive Foot care program. / Análisis de las reulceraciones en una unidad multidisciplinar de pie diabético tras la implementación de un programa de cuidado integrado del pie.

BACKGROUND AND OBJECTIVE: The aim of this study was to assess the risk factors associated to recurrent diabetic foot ulcers after implementing a new preventive comprehensive foot care (CFC) program carried out by a podiatrist and an endocrinologist at a multidisciplinary diabetic foot unit (MDFU) and its potential impact in decreasing recurrent ulcers. MATERIAL AND METHODS: A retrospective cohort study including consecutive patients who attended the MDFU for the first time from 2008 to 2014 complaining of a diabetic foot ulcer that finally healed. Patients were monitored until ulcer recurred or up to June 30, 2016. Maximum follow-up time was 8.1 years. Cumulative incidence of recurrent ulcers was analyzed during two periods: 2008-2010 (before CFC was implemented) and 2011-2014 (after implementation of CFC). RESULTS: A total of 280 subjects with a median age of 69.5 years (Q25:60,2-Q75:78) were included. Of these, 64.6% were males and 92.1% had type 2 diabetes mellitus. One hundred and twenty-six (45%) suffered recurrent ulcers. Median time to recurrent ulceration was 0.97 (Q25:0.44-Q75:1.74) years. Multivariate analysis showed sensory neuropathy (HR [95% CI] 1.58 [0.99-2.54], P=.050); minor amputation (HR [95% CI] 1.66 [0.12-2, 46], P=.011); and 2011-2014 period versus 2008-10 period (HR [95% CI] 0.60 [0.42-0.87], P=.007) to be factors independently associated to recurrent ulcers. CONCLUSIONS: Sensory neuropathy, minor amputation, and implementation of the CFC program were predictors of reulceration. Implementation of the CFC program was associated to a 40% reduction in reulceration. Prevention of recurrent ulcers is feasible and should be a priority in a MDFU.

Clinical characteristics and mortality in patients treated in a Multidisciplinary Diabetic Foot Unit. / Características clínicas y mortalidad de los pacientes atendidos en una Unidad Multidisciplinar de Pie Diabético.

BACKGROUND AND OBJECTIVE: This study reviews the clinical characteristics of patients with diabetic foot ulcer treated in a Multidisciplinary Diabetic Foot Unit (MDFU) and analyzes the mortality and factors associated with its survival. MATERIAL AND METHODS: Data from all patients who attended the MDFU for the first time for a diabetic foot ulcer during the 2008-2014 period were analized. The patients were followed until their death or until June 30, 2016, for up to 8 years. RESULTS: A total of 345 patients were included, with a median age (P25-P75) of 71 (61.5-80) years, and 321 (93%) had type 2 diabetes. They were characterized as patients with inadequate glycemic control, 48% had HbA1c ≥ 8% and high prevalence of chronic complications: 60.2% retinopathy, 43.8% nephropathy and 47.2% ischemic heart disease and/or cerebrovascular disease. A total of 126 (36.5%) patients died and 69 (54.8%) were due to cardiovascular disease. Survival measured by Kaplan-Meier declined over time to 69, 60 and 45% at 3, 5 and 7 years respectively. Cox's multivariate regression analysis showed the following variables associated with mortality, HR (95% CI): age 1.08 (1.05-1.11); previous amputation 2.24 (1.34-3.73); active smoking 2.10 (1.12-3.97); cerebrovascular disease 1.75 (1.05-2.92); renal dysfunction 1.65 (1.04-2.61) and ischemic heart disease 1.60 (1.01-2.51). CONCLUSIONS: Patients with diabetic foot ulcer are characterized by high morbidity and mortality, with cardiovascular disease being the most frequent cause of death. It is necessary to pay more attention to this risk group, tailoring objectives and treatments to their situation and life expectancy.

Trends in the incidence of lower limb amputation after implementation of a Multidisciplinary Diabetic Foot Unit. / Tendencia de la incidencia de amputaciones de miembro inferior tras la implementación de una Unidad Multidisciplinar de Pie Diabético.

BACKGROUNDS AND OBJECTIVE: Incidence of lower extremity amputations (LEA) in the population with and without diabetes mellitus (DM) was assessed after implementation of a Multidisciplinary Diabetic Foot Unit (MDFU) during 2008. MATERIAL AND METHODS: Non-traumatic LEA were analyzed, and those performed before (2001-2007) and after (2008-2014) introduction of the MDFU were compared. LEA were grouped by age and sex. Their incidence was expressed as a rate per 100,000 population per year, adjusted to the standard European population. RESULTS: A total of 664 LEA were performed during the 2001-2014 period, 486 (73%) of them in patients with DM. Total LEA incidence was 11.2/105 population in DM versus 3.9/105 in the population without DM. Incidence of major LEA in patients with DM significantly decreased from 6.1/105 population in the 2001-2007 period to 4.5/105 in the 2008-2014 period (p=.03). Joinpoint regression analysis also showed a reduction in the trend of incidence of major LEA in patients with DM, with an annual percentage change of -3.3% [95% CI, -6.2-0.3] (p=.025). No significant differences were found for all other incidences and trends in the diabetic and non-diabetic populations. CONCLUSIONS: Implementation of a MDFU has been shown to be associated with a significant reduction in major amputation rate in the diabetic population, although the results are not optimal yet. Both results and work at the MDFU should be improved.

The HIDEA School-Based Screening Scale for Teachers to Detect ADHD Markers in Elementary Students.

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) is associated with academic difficulties both short- and long-term. The aim of the study was to provide a new brief ADHD screening scale that could be easily used by teachers and educational professionals in elementary schools. METHOD: Participants were teachers of 158 children with a prior diagnosis of ADHD and 169 children without a diagnosis of ADHD. An initial pool of 38 items was generated from ADHD symptoms of both DSM-5 and CIE-10 criteria, as well from Conners 3, EDAH, SDQ and ADHD-RS-IV scales. RESULTS: A 5-item model showed the best fit (c2 = 7.04; d.f. = 5; p = .218; RMSEA = .035; CFI = .999; TLI = .999). The HIDEA total score was highly correlated with both ADHD-IN (r = .93; p<.001) and ADHD-HY (r = .87; p<.001). The ROC curve for the HIDEA total score gave an AUC value of .998 (95%, CI = [.994, 1.000]). HIDEA scale showed a good sensitivity (97%) and very good specificity (3%). CONCLUSION: The HIDEA scale has shown adequate psychometric properties. It is potentially useful for screening ADHD in elementary grade as part of a preventive strategies in school settings.

Health care of pregnant women with diabetes in Spain: Approach using a questionnaire.

OBJECTIVE: To ascertain how health care for pregnant women with gestational diabetes (GD) and pregestational diabetes (PGD) is organized, and to estimate the number of Pregnancy and Diabetes Units (PDUs) in Spain in 2013. MATERIAL AND METHODS: The Spanish Group of Diabetes and Pregnancy (GEDE) developed and agreed on a questionnaire based on the recommendations of the group. The questionnaire was sent to members of the Spanish Society of Diabetes and the Spanish Society of Endocrinology and Nutrition. RESULTS: Eighty-seven questionnaires were received from 81 hospitals, 4 outpatient specialty centers, and 2 primary healthcare centers, which accounted for 51% of the Spanish population and for 39% of births in 2013. GD was mainly diagnosed based on GEDE recommendations (98%), and less than 50% of women were reevaluated after delivery in primary care. Fourteen (26%) of the 53 centers identified as PDUs corresponded to a minimal model. Continuous subcutaneous insulin infusion (CSII) therapy was not available in 30% of centers, and 13% of hospitals had no preconceptional clinics. No nurse support was available in 20% of centers. CONCLUSIONS: Care of women with PGD has a fair coverage with PDU, but significant deficits still exist, for instance, in preconception clinic and CSII. However, organization of care for women with GD appears to be adequate. There are aspects in need of improvement such as integration of diabetes educators and coordination with primary care for postpartum reclassification.

[Relationship between vitamin D deficiency and metabolic syndrome in adult population of the Community of Madrid]. / Relación entre el déficit de vitamina D y el síndrome metabólico en población adulta de la Comunidad de Madrid.

BACKGROUNDS AND OBJECTIVE: Previous studies have suggested an association between MS and vitamin D deficiency, but data are not conclusive. This study was intended to find out if metabolic syndrome, according to the 2009 IDF/AHA/NHLBI, is associated to the presence of vitamin D deficiency. MATERIAL AND METHODS: A cross-sectional study was conducted on a sample of 326 subjects aged 18 years or older, recruited from a health center in Alcalá de Henares. Participants underwent an interview and a standardized clinical examination. In a second visit, blood tests were performed in 255 subjects to quantify serum levels of 25-hydroxyvitamin D (25 OH-VitD) and different laboratory parameters associated to MS. The association between vitamin D deficiency and metabolic syndrome (and each of its components) was examined. RESULTS: In the study population, MS prevalence was 36.1% and prevalence of vitamin D deficiency (25 OH-Vit D<20 ng/mL) was 56.3%. MS was more common in the group of patients with vitamin D deficiency (43.4%) than in the group with no deficiency (26.8%, P=.006), with an estimated prevalence ratio of 1.62 (95% CI: 1.13-2.31). Adjustment for age, sex, and body mass index did not change such association. CONCLUSIONS: There is a significant association between vitamin D deficiency and MS. Both conditions are highly prevalent in our population.

Salt-induced stabilization of apoflavodoxin at neutral pH is mediated through cation-specific effects.

Electrostatic contributions to the conformational stability of apoflavodoxin were studied by measurement of the proton and salt-linked stability of this highly acidic protein with urea and temperature denaturation. Structure-based calculations of electrostatic Gibbs free energy were performed in parallel over a range of pH values and salt concentrations with an empirical continuum method. The stability of apoflavodoxin was higher near the isoelectric point (pH 4) than at neutral pH. This behavior was captured quantitatively by the structure-based calculations. In addition, the calculations showed that increasing salt concentration in the range of 0 to 500 mM stabilized the protein, which was confirmed experimentally. The effects of salts on stability were strongly dependent on cationic species: K(+), Na(+), Ca(2+), and Mg(2+) exerted similar effects, much different from the effect measured in the presence of the bulky choline cation. Thus cations bind weakly to the negatively charged surface of apoflavodoxin. The similar magnitude of the effects exerted by different cations indicates that their hydration shells are not disrupted significantly by interactions with the protein. Site-directed mutagenesis of selected residues and the analysis of truncation variants indicate that cation binding is not site-specific and that the cation-binding regions are located in the central region of the protein sequence. Three-state analysis of the thermal denaturation indicates that the equilibrium intermediate populated during thermal unfolding is competent to bind cations. The unusual increase in the stability of apoflavodoxin at neutral pH affected by salts is likely to be a common property among highly acidic proteins.

Surgical site infection rates and risk factors in orthopedic pediatric patients in Madrid, Spain.

BACKGROUND: The objective of the study is to study surgical site infection (SSI) rates and risk factors in a pediatric population. METHODS: We conducted a prospective cohort study to estimate the SSI rate at a national pediatric referral center, covering all patients managed at the Orthopedic Surgery Department of the Niño Jesús Children's University Teaching Hospital from January 2010 through December 2012. Risk factors and antibiotic prophylaxis were monitored. A comparison between Spanish and US data was performed, with a breakdown by National Nosocomial Infection Surveillance risk indices. We also conducted a comparative study of SSI rates from 2010 to 2012 to assess the impact of the epidemiologic surveillance system. RESULTS: The study population of 1079 patients had a SSI rate of 2.8%. SSI rates were calculated for spinal fusion and other musculoskeletal procedures according to the National Nosocomial Infection Surveillance risk index. In the case of other musculoskeletal procedures, our SSI rates were 0.8 times lower than the overall Spanish rate, but higher than US rates for all risk categories. For spinal fusion procedures, our SSI rates were 1.2 times higher than the Spanish rates and 3.5 times higher than National Nosocomial Infection Surveillance rates. This latter finding should be interpreted with caution because it was based on a small sample. The multivariate analysis indicated that the only predictive factors of SSI were American Society of Anesthesiologists score and age. CONCLUSIONS: The surveillance program showed that for clean procedures, SSI incidence decreased from 4% in 2010 to 3.2% in 2011 and to 2.4% in 2012.